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Cardiac MR to determine culprit lesion 3 years after LCx stenting

Case Study
Yun, Chun-Ho, M.D. Mackay Memorial Hospital • Taiwan
Tsai, Cheng-Ting, M.D. Mackay Memorial Hospital • Taiwan
Yang, Fei-Shih, M.D. Mackay Memorial Hospital • Taiwan

Patient history

A 60-year-old male had PCI for LCx stenting 3 years ago. His risk factors are hypertension and hyperlipidemia. This patient with stable angina for a few weeks underwent Cardiac MR stress testing at Mackay Memorial Hospital.

MR examination

Achieva 3.0T with the 32-channel SENSE cardiac coil was used.
With persantine as a stressor, stress/rest perfusion was performed. Cine imaging of 2-chamber, 4-chamber and SAX is done, as well as delayed enhancement.
Multihance contrast medium was administered.
Total scan time was around 35 minutes.

Images

 Stress Negative DLE
Stress
Negative DLE
At stress perfusion, a perfusion defect is present at the anterior wall. There is no MR evidence of non-viable myocardium at delayed enhancement.


LCX  QCA: 77% LAD  QCA:55% RCA  QCA: 55%
LCX QCA: 77%
LAD QCA:55%
RCA QCA: 55%
Coronary angiography showed triple vessel disease. It means mismatch of MRI and angiography.


LCX  FFR: 0.88 LAD  FFR: 0.63 RCA  FFR: 0.86
LCX FFR: 0.88
LAD FFR: 0.63
RCA FFR: 0.86

FFR result revealed only LAD lesion is the flow-limiting lesion which compatible with stress MR finding.

Diagnosis

CMR findings are stress-inducible ischemia at the anterior wall of the left ventricle, suggestive of a flow limiting lesion at LAD.
Coronary angiography: LAD-p:55%, RCA-p:55%, LCx-m:77%

FFR: LAD: 0.63, RCA: 0.86, LCx: 0.88

Clinical impact of Cardiac MR stress testing

In this case, the MR result is not consistent with coronary angiography. Based on per-patient analysis, CMR has did a good job. But in per-vessel analysis, CMR cannot provide an accurate diagnosis of RCA and LCx. However, as we know, a high grade stenosis is not equal to a flow limiting lesion. Fractional flow reserve in this case demonstrates that only the LAD lesion has FFR<0.8, supporting the CMR finding. With CMR, we can provide the functional information to interventional cardiologists before the invasive angiography.

Related reading



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Jun 5, 2012

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Case Study
Achieva 3.0T
32ch SENSE Cardiac coil, Cardiac, Cardiac function, CMR, Ischemia, stenosis, stress test
 

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